Ongoing monitoring of specific quality indicators is an important component of the ICP Quality
Improvement (QI) program. Indicators are selected based on important aspects of care for ICP members including, but not limited to, utilizing medical/surgical, behavioral health and chemical dependency data. These indicators are relevant to the enrolled population; are designed to be reflective of high volume or high-risk services; encompass preventive, acute and chronic care and span a variety of delivery settings. Categories of indicators may include the following:
Quality Improvement Project (QIP) data Chronic Care Improvement Program (CCIP) HEDIS® Measures
Service Quality Improvement Project data Practitioner performance indicators Survey data
Utilization Management (UM) quality indicators/performance measures Case Management (the Model of Care required for all ICP members) quality
indicators/performance metrics
Waiver requirements (additional case management) quality indicators/performance metrics Utilization data
Complaint data
Access and availability data Membership data
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Quality Improvement Program
The ICP Quality Improvement Program is intended to reward the provider for maintaining high quality and patient satisfaction standards in the delivery of covered services as outlined in the MSA.
The Quality Improvement Program Clinical Measures and performance thresholds will be established by ICP on an annual basis. Quality Improvement Program Clinical Measures and performance thresholds may be modified by ICP to comply with the contractual requirements from IHFS.
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Quality Improvement Program Data Submission and Calculation
QIP Clinical Measures are usually based on ICP claims data, pharmacy data, outcomes data and medical record review. The PCP, or the medical group, as appropriate, is required to submit complete and
accurate data and supporting documentation for each of the QIP Clinical Measures as requested by ICP. The data must be submitted in a format acceptable to ICP and within the time period established in the QIP instructions.
All documentation requested by ICP to support any claims for payment must be received by ICP within seven days of the request for documentation, unless the QIP instructions allow more time for the PCP to provide such documentation. ICP may reduce or eliminate any payments that the PCP may be eligible for if the PCP either refuses or delays providing such documentation to ICP.
Oversight for the ICP Quality Improvement Program
The ICP Quality Improvement Committee (QIC) provides oversight and direction to the ICP Quality Improvement Program. ICP QIC brings multidivisional staff together with providers and members for the purpose of reflecting customer values.
Responsibilities of the QIC include:
Review and approval of the annual ICP Quality Improvement Program Descriptions Review and approval of the annual ICP Quality Improvement Work Plans.
Monitoring and analysis of reports on QI activities from subcommittees
Review and approval of annual ICP Quality Improvement Program Evaluation. Review and approval of Quality Improvement Projects
Recommendation of policy decisions
Analysis and evaluation of the results of QI activities
Review of analysis of significant health care disparities in clinical areas
Review of analysis of information, training and tools to staff and practitioners to support culturally competent communication
Review of analysis of on-site audit results to understand the differences in care provided and outcomes achieved
Review of analysis and evaluation of member complaints and appeals Review of analysis and evaluation of populations with complex health needs
Ensuring practitioner participation in the ICP QI Program through project planning, design, implementation and/or review
Institution of needed actions Ensuring follow-up, as appropriate
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Member’s Rights and Responsibilities
ICPis committed to ensuring that enrolled members are treated in a manner that respects their rights as individuals entitled to receive health care services. ICP is committed to cultural, linguistic and ethnic needs of our members. ICP policies address the issues of members participating in decision-making regarding their treatment; confidentiality of information; treatment of members with dignity, courtesy and a respect for privacy; and members’ responsibilities in the practitioner-patient relationship and the health care delivery process. All members in the ICP program are expected to have individualized care plans. Members and/or their caregivers are key participants in the development and implementation of the care planning process.
ICP also holds forth certain expectations of members with respect to their relationship to the managed care organization and their individual health care practitioners. These rights and responsibilities are reinforced in member and provider communications, including the BCBSIL website.
Various components of the ICP QI Program incorporate elements of member rights, which may include: Policies on inquiries and complaints
Policies on appeals
Policies on quality of care complaints Access and availability standards
Member involvement in satisfaction surveys
Member involvement in the development of their care plan and in their Interdisciplinary Care Team
In addition, the policy on Member Rights and Responsibilities further defines the relationship between the member, the practitioner and ICP.
Quality of Care Issues
The Quality Improvement Program includes aggregation and analysis of trends for possible quality of care issues. All member grievances regarding quality of care, regardless of whether they are filed orally or in writing are responded to in writing. A quality of care complaint may be filed through ICP’s grievance process and/or a Quality Improvement Organization (QIO). A QIO must determine whether the quality of services (including both inpatient and outpatient services) provided or arranged by ICP meet
professionally recognized standards of health care, including whether appropriate health care services have been provided and whether services have been provided in appropriate settings. In situations where the member files a quality of care grievance with both the QIO and ICP, ICP is required to cooperate with the QIO in obtaining documentation and in resolving the grievance.
The QIO is comprised of practicing doctors and other health care experts under contract to the federal government to monitor and improve the care given to Medicaid members. QIOs review complaints raised by members about the quality of care provided by physicians, inpatient hospitals, hospital outpatient departments, hospital emergency rooms, skilled nursing facilities (SNFs), home health agencies (HHAs) and ambulatory surgical centers. The QIOs also review continued stay denials for members receiving care in acute inpatient hospital facilities, as well as coverage terminations in SNFs, HHAs and
Comprehensive Outpatient Rehabilitation Facilities (CORFs).
All quality of care grievances filed with ICP are investigated. Based on the investigation, if there is validation of quality concerns, specific actions may be taken to help address and/or avoid a recurrence.
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Member Satisfaction
The monitoring, evaluation and improvement of member satisfaction are important components of the ICP QI Program. This is accomplished through the use of surveys, as well as through the aggregation,
trending and analysis of member complaint and appeal data including the following categories: quality of care, access, attitude and service, billing and financial issues and quality of the practitioner’s office site. In addition to the administration of surveys, ICP encourages members to offer suggestions and express concerns utilizing customer service telephone lines and request for comments in survey instruments. The following surveys are some of the tools utilized in the assessment of member satisfaction:
CAHPS Survey
Behavioral Health Survey, if applicable
In addition to assessment of member satisfaction, providers are surveyed to assess their satisfaction with various aspects of the ICP program including Utilization Management and Case Management. In addition, ICP practitioner needs and expectations may be voiced at regular open meetings including ICP
Administrative Forums and Managed Care Roundtables. ICP uses information from practitioner surveys in ongoing program evaluation.
ICP providers may be surveyed to assess their overall satisfaction. For example, they may be asked about their satisfaction with ICP support staff (e.g., Provider Network Consultants, Nurse Liaisons) as well as other questions related to network support. Information obtained through surveys is utilized in network development and planning.
ICP also solicits input from providers and facilities by the following means: ICP Consumer Advisory Committee
Telephonic encounters Ad hoc advisory groups Face-to-face meetings
HEDIS®
HEDIS Performance Measures results are evaluated on an annual basis to monitor improvement. HEDIS data are collected from claims, encounters and may be supplemented with medical chart review. HEDIS data submitted to National Committee for Quality Assurance (NCQA) and other entities are audited by an NCQA certified HEDIS auditor.
Continuity and Coordination of Care
Continuity and coordination of care are important elements of care and as such are monitored through the ICP QI Program. Opportunities for improvement in the continuity and coordination of medical care may be selected from across the delivery system, including settings, transitions in care and patient safety. In addition, coordination between medical and behavioral health care is also monitored.
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Practice Guidelines
Development and Updates
ICP has developed and implemented preventive and clinical practice guidelines and criteria to assist clinical decision-making by patients and practitioners, provide standards and measures to help assess and improve the quality of care and encourage uniformity and consistency in the provision of care. Clinical practice guidelines and clinical criteria are developed and derived from a variety of sources, including recommendations from specialty and professional societies, consensus panels and national task forces and agencies, reviews of medical literature and recommendations from ad hoc committees. Clinical practice guidelines and clinical criteria are provided for informational purposes only and are not a substitute for the independent medical judgment of health care providers. Providers are required to exercise their own medical judgment in providing health care to members.
The ICP Clinical Management Committee may review and, as necessary, update clinical criteria annually and practice guidelines at least every two years.
Dissemination and Implementation
Clinical criteria and preventive and clinical practice guidelines are disseminated to providers through the ICP Provider Manual posted in the Standards and Requirements section of the BCBSIL Provider website. The clinical practice guidelines are applicable to all BCBSIL products.
Service Quality Improvement
The ability to provide valuable health care correlates strongly with services that support the managed care organization and health care delivery system. Further, satisfaction with ICP is often derived from the quality of service the members receive. Service standards have been established to help prevent issues, whenever possible, and provide consistent, timely and accurate information and assistance to members, physicians, providers and other customers. The standards are routinely monitored. Surveys and
complaints are monitored to help ensure the standards established are appropriate and meet the needs of the organization and customers. Service indicators include:
Inquiry and complaint rates Telephone access standards
Results from member and provider appeals
Compliance with Provider and practitioner access standards Results from member and Provider surveys
Each of the standards allows member satisfaction with key service indicators to be assessed and interventions implemented as necessary. The key areas of focus are likely to include, but are not limited to,
Customer service Claims payment
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External Accountability External Accountabilities
The ICP QI Program is designed to meet all applicable state and federal requirements (e.g., HIPAA, etc.). ICP staff monitors state and federal requirements related to quality improvement and reviews program activities to help assure compliance. In addition, if ICP achieves external accreditation/certification, maintenance of such accreditation/certification is monitored through the ICP QI Program.
Quality Improvement Program Documents
ICP QI Program Description
The ICP QI Program description is reviewed annually and may be updated as needed.
QI Work Plan
The ICP QI Program Work Plan is initiated annually based upon the planned activities for the year and includes improvement plans for issues identified through the evaluation of the previous year’s program. The scope of the ICP Work Plan includes aspects of the ICP QI Program and the activities appropriately linked to the established goals and objectives. The work plan may include time frames for accomplishing each planned activity. The document may be updated throughout the year to reflect the progress on QI activities and new initiatives as they are identified.
ICP QI Program Evaluation
On an annual basis, the ICP QI Program is evaluated. The ICP QI Program is then updated accordingly. The ICP evaluation process includes:
A description of completed and ongoing QI activities that address quality and safety of clinical care and quality of service rendered by network providers.
Trending of measures to assess performance in the quality and safety of clinical care and quality of service rendered by network providers.
Analysis of the results of QI initiatives, including barrier analysis
Evaluation of the overall ICP QI Program, including progress toward influencing network-wide safe clinical practices.
Disclosure of the ICP QI Program Information